REPORT 

ON 




SUBMITTED BY THE 

Medical Society of the District of Columbia 

TO THE 

COMMITTEE ON THE DISTRICT OF COLUMBIA 

OF TUE 

U. S. HOUSE OF REPRESENTATIVES, 
JUNE 14, 1894. 

COMMITTEE: 

S. C. BUSEY. C. H. A. KLEINSCHMIDT. 

WILLIAM W. JOHNSTON. G. WYTHE COOK. 
G. L. MAGRUDER. S. S. ADAMS. 

D. W. PRENTISS. 



WASHINGTON : 

GOVERNMENT PRINTING OFFICE. 
18 9 4. 



REPORT 

ON 

TYPHOID FEVER IN TI DISTRICT OF COLUMBIA 



SUBMITTED BY THE 




TO THE 

COMMITTEE ON THE DISTRICT OF COLUMBIA 

OF THE 

U. S. HOUSE OF REPRESENTATIVES, 
JUNE 14, 1894. 

COMMITTEE: 

S. C. BUSEY. C. H. A. KLEINSCIIMIDT. 

WILLIAM W. JOHNSTON. G. WYTHE COOK. 
G. L. MAGKUDER. S. S. ADAMS. 

D. W. PRENTISS. 



WASHINGTON: 

GOVERNMENT PRINTING OFFICE. 
18 9 4. 



V) 



TYPHOID FEVER IN THE DISTRICT OF COLUMBIA. 

[Report submitted to the Medical Society, June 6, 1894.] 

The committee appointed by the Medical Society to report upon the 
subject of typhoid fever in the District of Columbia begs leave to make 
the following report : 

The consideration of this subject by the Society is justified and 
demanded by the very great prevalence of typhoid fever and by the 
large number of deaths, which gives Washington a most unenviable 
position among American cities. 

It is right that a disease which is known to be preventable, which 
has been almost abolished in some of the capitals of Europe, should 
receive here, in the capital of this country, the closest study and atten- 
tion. If the causes of its persistence are known — if, above all, these 
causes can be removed — it is our part and duty to make the facts public 
and to arouse public attention to the necessity and urgency for action. 
Who is better fitted to speak authoritatively on this subject than the 
Medical Society of the District, whose members are in daily contact 
with the disease, and who have every opportunity to study the modes 
of its diffusion among our population*? 

The committe has endeavored to present, as briefly as possible, the 
data upon which an intelligent judgment can be formed. The magni- 
tude of the task of making a complete study of typhoid fever in all 
of its aspects must be apparent to all, and the committee must ask in- 
dulgence for the imperfection of the report in many of its details. 
Much could only be touched upon, much had to be omitted. The im- 
portance of the subject demands continued observation and study, and 
it is suggested that the work be continued from year to year in whatever 
way which may seem best to the society. 

The committee is indebted for much valuable assistance to the Dis- 
trict Commissioners and their assistants, who have all shown great in- 
terest in the work of the Society in this investigation. 

The accompanying report will consider — 

1. The prevalence and mortality of typhoid fever in the District. 

2. The relations of the dissemination of the disease to the — 
(a) Public water supply; 

(&) To the pollution of the soil with the leakage from privies, from 
defective sewers, and from the backing up of sewage from tidal move- 
ments j 

3 



4 



TYPHOID FEVER IN THE DISTRICT OF COLUMBIA. 



(c) To the drinking of well or pump water; 

(d) To contaminated milk and to other causes. 

3. The difference in mortality in different areas of the city, with a 
view to discover the causes of the disease. 

4. Conclusions based upon the foregoing data, as to what measures 
should be taken to diminish the spread of the disease. 

PREVALENCE AND MORTALITY OF TYPHOID FEVER IN THE DISTRICT 

OF COLUMBIA. 

The following table gives the statistics of typhoid fever in the Dis- 
trict of Columbia from 1881 to 1893, the ratio of deaths from all causes, 
and the total deaths, based upon the records of the health office of the 
District : 



Table I. — Typhoid fever in the District of Columbia, 1881 to 1893, inclusive. 



Years. 


Population. 


Deaths 
from ty» 
phoid fever. 


Ratio of 
deaths from 
typhoid fe- 
ver to 1,000 
deaths from 
all causes. 


Ratio of 
deaths from 
typhoid fe- 
ver to each 
10,000 popu- 
lation. 


Total 
deaths. 


1881 




183, 000 


67 


16.2 


3.6 


4,136 


1882 




188, 653 


120 


26.2 


6.3 


4, 571 


1883 




191, 980 


92 


21.4 


4.8 


4,286 






200, 000 


76 


16.0 


3.8 


4, 814 


1885 




200, 000 


124 


25.0 


6.2 


4, 998 


1886 




205, 000 


125 


27.2 


6.2 


4. 674 


1887 




210, 000 


116 


25.0 


5.5 


4, 685 






225, 000 


168 


33.6 


7.4 


5, 040 


1889 




250, 000 


170 


33.3 


6.8 


5, 152 


1890 




250, 000 


208 


37.7 


8.3 


5, 564 


1891 




250, 000 


208 


36.6 


8.3 


5, 720 


1892 




260, 000 


183 


30.4 


7.0 


6, 098 


1893 




285, 000 


186 


28.6 


6.5 


6, 452 



From 1881 there has been an almost uninterrupted yearly increase 
of the death rate, the highest point being reached in 1890, with a ratio 
of 8.3 to 10,000 inhabitants. In 1891 the rate was 8.3; in 1892 it had 
dropped to 7, and in 1893 to 6.5. The lowest mortality, 3.6 and 3.8, 
was in 1881 and 1884. The past nine years show a greater number of 
deaths, representing a larger number of cases, than at any previous 
time. In the past two years the ratio has been less than in the pre- 
vious seven years. An exception should be made to the percentage of 
1893, as given in Table I. It is based upon an assumed increase of 
25,000 population in one year. This is not thought to be justified by 
the actual increase of previous years, and the percentage of 6.5 as the 
ratio of deaths in this year should be much higher, as high, certainly, 
as 1892, which is 7 to 10,000 population. 

The actual number of annual deaths has increased from 67 in 1881, , 
to 208 in 1890 and 1891, both years reaching the same number. In 
1892 there were 183 and in 1893 186 deaths. 



Chart I 

ACTUAL NUMBER OF DEATHS AND COMPARATIVE DEATH-RATE FROM 
TYPHOID FEVER, MALARIAL DISEASES, TYPHO-MALARIAL FEVER, 
AND DIARRHCEAL DISEASES, FROM 1881 TO 1893. 



POPULATION 
DEATHS JTPHOID 
"TYPHO-MALARIA 
" MALARIA 
" DIARRHOEA 



I88II882I883I884I885I886I887I888I8891890I89I I892I893 

183060 1 158655'l9(980 200000200000 205000 2 10000225000250000250000250000260000 285000 

1161 168! 170 |208 12081 183 j!86 



67 120 ! 92 76 
31 1 44 38 34 
93 112 93 66 
368 514 557 388 



124 
30 
78 
399 



125 
17 
54 
325 



22 ! 14 
99 62 
393 37! 



28 35 
80 68 
477 482 



20 ! 23 



56 
372 



72 
476 




PHOTO-LITHO.. WASHINGTON. O. C. 



Typho-Malarial Fever, 
Malarial Diseases, 



Typho-Malarial Fever and Malarial Diseases Combined, 

Typhoid Fever, 

Diarrhoeal Diseases, • 



TYPHOID FEVER IN THE DISTRICT OF COLUMBIA. 5 



Table II. — Deaths from typhoid fever in Washington from 1883 to 1892, inclusive. 



Years. 


White. 


Colored. 


Total 
number of 
deaths. 


Number 
of deaths 
to 10,000 

popula- 


Total 
number of 
deaths. 


Number 
of deaths 
to 10,000 
popula- 




49 

53 
83 
81 
72 
95 
96 
118 
129 
107 


o. o 

4. 05 

6.3 

5.9 

5.1 

6.3 

5.6 

6.9 

7.7 

6.1 


43 
23 
41 
47 
44 
73 
74 
90 
79 
76 


6. 5 
3! 3 
5.9 
7. 05 
6.2 
9.7 
9.2 
11.2 
9.9 
8.9 




1885 




1887 , 


1888 


1889 


1890 


1891 


1892 






5.8 




7.8 









In Table 11 the ratio of deaths in the white and colored population 
is given, in the ten years from 1883 to 1893, inclusive. The whites had 
an average mortality of 5.8 and the blacks of 7.8 to 10,000 population. 
Here, as in the general mortality statistics, the high death rate is due 
largely to the greater fatality of typhoid fever among the colored race. 

Typho-malarial fever is not included in these tables. If deaths from 
this cause were added to those from typhoid fever, as they should be 
done, the percentage of fatal typhoid cases would be much higher than 
here given. The present drift of opinion is to abandon this term alto- 
gether, as it leads to continued confusion and error. That it is being 
abandoned may be inferred from the decrease in the death returns 
from this cause, pari passu, with increase in the returns of typhoid 
fever.. (See Chart 1.) 

Table III. — Deaths from typho-malarial fever and malarial fevers in the District of 
Columbia and in Baltimore from 1881 to 1893. 



Deaths from 
typho-mala- 
rial fever in 
District of 
Columbia. 


Deaths from 
typho-mala- 
rial fever in 
Baltimore. 


Mortality 
from mala- 
rial fevers in 
District of 
Columbia. 


Mortality 
from mala- 
rial fevers in 
Baltimore. 


31 


50 


99 


27 


44 


44 


112 


22 


38 


48 


93 


24 


34 


66 


66 


29 


30 


75 


78 


27 


17 


58 


55 


30 


22 


55 


99 


28 


14 


41 


62 


24 


28 


33 


80 


23 


35 


54 


68 


19 


20 


39 


56 


26 


23 


33 


62 


19 


18 


31 


85 


25 



The mortality from malarial fevers, as seen in the above table, is 
still greater than seems possible the progressive falling off in the 
number of fatal cases, as seen in Chart I, shows either that malarial 
diseases are on the decrease or that there is a change of opinion as to 
the nature of many cases of fever. 



6 



TYPHOID FEVER IN THE DISTRICT OF COLUMBIA. 



In order to represent more clearly the extent and fatality of typhoid 
fever in this city, maps have been prepared, which accompany this 
report. 

Map I is compiled from the maps of the health office, and is made up 
of an aggregation of the fatal cases of typhoid fever occurring in 
residences in five years from 1888 to 1892, inclusive, and shows the 
number of deaths (in red dots) during that period. 

There were in the whole city 626 deaths in residences from this 
cause. 

The same map shows (in blue dots) the number of deaths from the 
malarial fevers, including the deaths from typho-malarial fever. The 
actual number of deaths from typho-malarial fever in the five years 
was 120, an annual average of 24. There were 243 deaths from malarial 
fevers in the same period in residences, an annual rate of 48. No one 
can believe that malarial fevers have any such mortality in the District, 
and we are forced to the conclusion that many of the fatal cases of 
malarial fever were cases of typhoid fever. In public institutions and 
in the county the fatal cases of malarial fever numbered 130 in the five 
years, making a total of 493 deaths from this cause. 

The map shows that there is a coincidence in locality of the deaths 
from typhoid fever, typho-malarial fever, and malarial fevers. 

Deaths in the public institutions, hospitals, and in the county are not 
represented on this map ; there were 201 in the hospitals and 90 in the 
county. 

Map III shows the locality of deaths from diarrheal diseases. Here, 
too, the area of greatest mortality is the same as that of typhoid and 
the malarial fevers. 

Table IV gives a comparative statement of the mortality from 
typhoid fever here and in a few of the chief cities of this country and 
Europe. The average annual mortality in the District to 10,000 popu- 
lation was 6.2 j in Philadelphia, 6.3 ; Chicago, 7.8 ; Boston, 4.1; Balti- 
more, 4.1; New York, 3.1; Paris, 6.1; Berlin, 2. 



Table IV. — Comparative statement of the number of deaths per 10,000 inhabitants from 
typhoid fever in the cities named, during the years 1881 to 1893, inclusive, and the 
general average therein. 



Tears. 


District 
of Colum- 
bia. 


Boston. 


New 
York. 


Philadel- 
phia. 


Chicago. 


Balti- 
more. 


Berlin, 
Germany. 


Paris, 
France. 


1881 


3.6 
6.3 
4.8 
3.8 
6.2 
6.2 
5.5 
7.4 
6.8 
8.3 
8.3 
7 

6.5 


5.2 
5.1 
4.6 

5 

3.8 
3.4 
4.6 
4.1 
4.1 
3.4 
3.3 
2.9 


4.8 
4 

4.7 
3.5 
2.9 

3 

2.9 
2.3 
2.5 
2.2 
2.3 
2.2 


7.4 
7.7 
6.3 
6.1 
6.4 
6.3 
6.2 
7.7 
7 

6.3 
6.4 
1 4.9 




5.7 

4.6 

3.4 

4 

4 

3.8 
3.4 
3.8 
4.5 
5.6 
3.3 
4.2 


4.7 

3 
3 

1.8 

1.9 
1.6 
1.3 
1.4 
1.3 
1.9 
0.9 


8.7 
14.3 
8.4 
7 
6 

4.2 
6.1 
3.3 
4.4 
2.9 
2,2 


1882 




1883 




1884 




1885 

1886 

1887 

1888 

1889 

1890 

1891 


7.4 
6.8 
5 

4.5 
4.1 
8.4 

16 

10.3 


1893 






















6.2 


4.1 


3.1 


6. 31 


7. 81 


4. 19 


2.08 


6.14 



Chart II 




THE NOflRlS peteps I 



TYPHOID FEVER IN THE DISTRICT OF COLUMBIA. 7 



Chart II, adapted from the valuable report of Erwin F. Smith, now 
of the Agricultural Department, on The Influence of Sewerage and 
Water Supply on the Death Rate in Cities, shows the comparative 
mortality in different cities of this country and Europe. We will have 
occasion to refer to this chart later. 

CAUSES OF THE PREVALENCE OF TYPHOID FEVER. 

What interests us most is to trace the cause of the disease as it 
exists here, and in so doing it is assumed in this report that the question 
of its etiology is definitely settled, and that the conditions underlying 
its prevalence are (1) an impure water supply, (2) the imperfect drain- 
age of a polluted soil, (3) infected milk, (4) and other causes. 

1. The water supply of our city and the District comes chiefly from 
two sources, the Potomac River and the wells which are scattered 
about the city and county. 

Washington, out of fifty of the largest cities, stands second in the 
list, with a per capita and per diem public supply of 177 gallons of 
water. Only Buffalo, with 196 gallons, is better supplied, while Phila- 
delphia has 111 gallons ; Baltimore, 92 j Boston, 89 j and New York, 74. 

Much of our public water supply is used in Government buildings 
and in public fountains, and the per capita estimate is not a fair one. 

It is not possible to compare the extent of typhoid fever in cities 
with abundant water supply with those which have an imperfect 
supply, or none at all, for cities well supplied with water are at the 
same time furnished with a good sewerage system, and it is not possi- 
ble in most cities to separate these conditions so as to discover the 
influence of water supply alone. 

The example of Dantzic, however, shows that an abundant water 
supply alone does not diminish the death rate. This city was supplied 
with water in 1869 and sewered in 1872. No marked diminution in the 
death rate of typhoid fever occurred until after the introduction of the 
sewers. Washington, with a daily individual supply of 177 gallons, has 
an average annual mortality of 6.2, while New York, with 74 gallons per 
capita, has 3.1 deaths yearly to 10,000 population. Abundance of water 
alone, as might well be supposed, does not limit the spread of typhoid 
fever. 

There is evidence enough to show that the public water supply may 
be contaminated with typhoid bacilli, and thus propagate the disease. 
The epidemic at Providence, E. I., in November, 1888, which was traced 
to the pollution of the water of the river with fecal matter from typhoid 
cases, 3J miles above the pumping station, is a case in point. The bacilli 
were found by Prudden and Ernst in the filters of the Providence houses. 
It is an admitted fact that the disease has often been originated in this 
way, but it is a question as to what value this mode of infection has as 
compared with others. Does the typhoid fever, which is the chief 
endemic fever of Washington, owe its continued existence to recur- 



8 TYPHOID FEVER IN THE DISTRICT OF COLUMBIA. 



ring or continued infection from this source*? Would we eliminate the 
disease by purifying the Potomac supply and destroying all its organic 
life? 

The Potomac water has been subject to very careful analyses, and, 
" in general, the water may be said to be in excellent condition and to 
compare extremely favorably * * * with that of other cities. 
Its chief defect " is " the presence of suspended clay in the winter v 
and after heavy rains in any season.* 



Table V. — Chemical analysis of Potomac water — averages 1888. 
[Results in parts per million.] 









Nitrogen as- 










Total 
solids. 


Free 
ammonia. 


Albumi- 
noid 
ammonia. 


Nitrites. 


Ni- 
trates. 


Oxygen 

con- 
sumed. 


Chlo- 
rine. 


Highest (1888) 


164 


.0600 


.2720 


.018 


2. 32 


4. 30 


5.0 


Lowest (1888) 


69 


.0000 


.0320 


.000 


.08 


.76 


3.0 


Average (1888) 


111 


.0170 


.1190 


.000 


.97 


1. 98 


4.2 


Highest (1889, to September) 


192 


.0560 


.4520 


.012 


1. 80 


3.32 


5.8 


Lowest (1889) 


76 


,0000 


.0600 


.000 


.50 


.88 


3.5 


Average (1889) 


110 


.0190 


.2140 


.000 


.82 


1. 82 


4.2 


Highest (1889, to September) 


270 


.3920 


.6520 


Trace. 


.8 


3.80 


5.0 


Lowest (1890, October) 


80 


.0000 


.0600 


.000 


.0 


.82 


4.0 




136 


.041 


.295 


.000 


.7 


1. 85 


4.3 


Highest (1890, to October) .......... 


132 


.0140 


.1200 


Trace. 


1.0 


3.30 


4.5 




76 


.0000 


.0200 


.000 


.3 


.56 


4.0 


Average 


104 


.0043 


.0627 


.000 


.6 


1. 97 


4.3 


Highest (1891-'92) 


168 


.0080 


.1600 


Trace. 


.8 


3. 96 


6.0 




82 


.0000 


.0200 


.090 


Trace. 


.78 


4.0 




113 


Trace. 


.0640 


.000 


.6 


1. 85 


4.3 


Highest (1892-'93) 


159 


.0520 


.1240 


.000 


.6 


4. 50 


5.0 




90 


.0000 


Trace. 


.000 


.5 


.78 


4.0 




125 


.0200 


.0661 


.000 


.6 


1. 64 


4.7 



The value of the so-called biological analyses of drinking water is, as 
Theobald Smith says (Medical News, Philadelphia, April 9, 1887), still 
very unsettled. As the result of one year's observation made by him, a 
relation was found between turbidity and the presence of bacteria. 
Bacteria were most abundant in winter, January and February having 
the highest average; August, September, and October, the months of 
the greatest prevalence of typhoid fever, having the lowest. Bacteria, 
most of which were harmless, were most abundant after heavy rains, 
and their presence in association with turbidity proved the then source 
to be from the washing of the surface of the soil. 

In the latest bacteriological report on Potomac water Theobald Smith 
adheres to this statement, and says that fecal bacteria and turbidity 
were coincident; that is, that rainfall carries into the Potomac what 
ever may happen to be on the surface of the soil, clay, manure from the 
fields, inorganic or organic matter of any sort. The nature of the 
country through which the Potomac flows, much of it being mountain- 
ous, as well as the absence of large cities on its banks, diminish the 
risks of infection from this source. As the country comes more and 
more under cultivation turbidity and impurity from the washing of 



*Beport of Engineer Department, District of Columbia, year ending June 30, 
1892, p. 77. 



Chart IV. 




THE NORRIS PETERS CO. PHOTO-UTHO.. WASHINGTON. D C. 



TYPHOID FEVER IN THE DISTRICT OF COLUMBIA. 



9 



plowed and manure covered land will be more common. The possibility 
of the introduction into the water of the microorganism of typhoid 
fever is dependent upon its presence in localities washed by the Poto- 
mac and its tributaries. 

CONTAMINATED WELL WATER. 

The question, after all, is not whether typhoid fever can be propa- 
gated by the drinking of Potomac water, but whether, as a matter of 
fact, it is usually propagated in this way. Before this question can be 
determined other probable sources of origin must be considered. 

It is an unjustifiable conclusion that because fecal bacteria are found 
in Potomac water, therefore typhoid fever is usually propagated by the 
drinking of Potomac water. Bacteriology may lead us astray here, and 
data of a very different sort must receive due weight before a logical 
conclusion can be reached. 

Consideration must now be given to the relations of the mortality of 
typhoid fever and its distribution in different sections of the city to 
the pollution of the soil by the leakage from privies, and to the drinking 
of contaminated well water. 

The truth of the theory may be considered as established that there 
is a relationship between pollution of the soil with human excrement 
and the drinking of well water contaminated with the poison of typhoid 
fever contained in this excrement. The converse of this has also been 
absolutely proved that typhoid fever can be diminished — almost elimi- 
nated — by a proper purification of the soil and the drinking of pure 
water. Facts will be alluded to further on which will illustrate this 
point. 

Out of a total of 1,174 squares in Washington and Georgetown 
deaths from typhoid fever occurred in 426 squares, or one death in 
about two and two-third squares. 

If the city is arbitrarily divided into four sections, Georgetown mak- 
ing the fifth, and the number of deaths from typhoid fever during the 
last five years be marked in the localities in which they occurred, it 
will be seen (see Map I) that there is a great difference in the distribu- 
tion of mortality. In region 1 (all that part of the city south of East 
Capitol street and the public grounds, including the southeast and 
southwest parts of the city) there is a very large number of cases. In 
this area there were 197 fatal cases in 131 squares. In region 2 (east 
of North Capitol street and north of East Capitol street) in 59 squares 
there were 84 deaths. In region 3, comprehending all that part west of 
North Capitol street and east of Thirteenth street and north of the public 
grounds, in 116 squares there were 179 cases. In region 4, west of Thir- 
teenth street to Georgetown and north of the river to Florida avenue, 
in 82 squares there were 114 deaths. In Georgetown in 38 squares 
there were 52 fatal cases. Assuming that each death represents 10 
cases of typhoid fever, in the five years there were about 6,260 cases in 



10 TYPHOID FEVEE IN THE DISTRICT OF COLUMBIA. 



Washington, at the rate of over 1,200 cases a year. Of these there 
were nearly 400 cases a year in the southeast and southwest districts, 
170 in the northeast, 360 in the middle region, 230 in the northwest, 
and 100 in Georgetown, 400 in hospitals and public institutions, and 190 
in the county. If we add the cases occurring in hospitals and the county 
to those in the city proper we have a total of 9,220 cases in five years, 
an annual average of 1,444 cases. 

The percentage of deaths from typhoid fever in each of these divi- 
sions to the contained population is : 



Eegion. 


Population 

of region. 
(Police cen- 
sus, 1892.) 


Total deaths 
from typhoid 
fever in five 
years in each 
region. 


Annual 
rate of mor- 
tality to 
10,000 popu- 
lation in each 
region. 


I. (South) 




§2, 218 


197 


6.3 






26,278 


84 


6.2 


III. (Central) 




70, 865 
49, 969 


179 


5 






114 


4.6 






16, 344 


52 


6.3 






30, 429 


95 


6.2 







The interesting fact is to be noted in this table that the annual rate 
of mortality of the whole District being 6.2, that of the northwest sec- 
tion is 4.6; central region, 5; south, east, Georgetown, and the county 
having each the same average, practically, as that of the total District 
average. 

The close relation of a soil polluted by sewage to typhoid fever prev- 
alence is admitted to be a causal relationship, and no argument need 
here be adduced to support a theory so universally adopted. In Wash- 
ington and the District there are three modes of infection of the soil 
with human excreta and sewage : 

(1) The overflow and leakage from privies. 

(2) The leakage from defective drain pipes in the soil. 

(3) The backing up of sewage in the sewers draining the lower parts 
of the city and the flooding of basements and cellars. 

The existence of the privy method of disposing of human excreta in 
cities is sufficient evidence of a contaminated soil. 

Map No. 4 shows the numerical distribution of the privies of Wash- 
ington. There are in the city limits 8,959 box privies, 5,133 in the 
county, a total of 14,092. 



In the first division (south) there are 3, 994 

In the second division (northeast) there are 941 

In the third division (central) there are 1,086 

In the fourth division (north and west) there are 1, 761 

In the fifth division (Georgetown) there are 1, 177 



Total 8,959 



Squares 743 to 795 in the southeast region may be cited as an exam- 



TYPHOID FEVER IN THE DISTRICT OF COLUMBIA. 11 

pie of the relative distribution of privies and closets with sewer con- 
nections: 



Square. 


Privies. 


Closets. 


743 


82 


13 


766 


23 


6 


768 


14 


3 


770 


41 


14 


799 


21 


19 


795 


24 


22 




289 


355 



In fourteen squares in the northwest part of the city there were 153 
privies and 297 closets. 

The report of the inspector shows that for the nine years ending 
June 30, 1891, there were 42,197 full or overflow privies reported, 6,455 
boxes with leakage, and 663 old and dilapidated boxes. In one year, 
1892, there were 465 boxes noted with leakage. It is difficult to ascer- 
tain the extent to which the saturation of the soil takes place in this 
way, but the above facts demonstrate that the saturation with excre- 
mentitious matter is a necessary result of such conditions. 

Every report of the engineer department of the District govern- 
ment contains a statement as to the relaying of pipe sewers. In the 
year 1892 there were 1,534 linear feet of sewer pipe which were taken 
np and relaid; 8,438 linear feet of obstructed sewers were replaced. 

These sewers were faulty in gradient, alignment, and because of defective joints, 
allowing the intrusion of tree roots, and in quite a number of cases they were of 
insufficient size. They were all laid under contracts made with the board of public 
works, in 1871-'74. (Report upon the sewerage of the District of Columbia, by 
board of sanitary engineers, June, 1890.) 

All pipe sewers laid prior to 1874 require to be replaced by those of 
suitable construction, with joints protected by concrete. It need not 
be added that such defective sewerage conditions permit the satura- 
tion of the soil with fecal matter. 

A third cause, which prevents thorough drainage of the soil and 
adds to the dangers from saturation with sewage, is found in the fact 
that from the foot of Gapitol Hill westerly to the Potomac Eiver there 
is a long, flat area only a few feet above high tide. To the north and 
east the ground rises; the soil of the lower area is moist, that of the 
elevated territory is composed of compact gravel, clay, and loam, and 
is comparatively dry. Owing to the absence of slope, and, therefore, 
of scouring velocities in the sewers in the south and east, accumulations 
take place in the sewers, which are added to by the eu trance of tide 
water. In the Tiber Creek sewer these deposits reached 2 to 3 feet in 
depth and several thousand feet in length, reaching nearly to the pres- 
ent District building. The daily effect of the entrance of the tidal 
current into the sewer is to prevent the complete emptying of the drains, 



12 TYPHOID FEVER IN THE DISTRICT OP COLUMBIA. 

and in times of flood great quantities of noxious sewage is carried into 
cellars and basements. 



The drinking of the infected waters of wells has long been known to 
be a mode of propagation of typhoid fever. If the soil of the city is 
receiving a considerable portion of the excreta of typhoid cases — if 
much of that soil is badly drained and wet with returned sewage — is 
it possible to avoid the danger of the fouling of well water ? 

In that low section of the city in which there is the most imperfect 
drainage, in which the soil is most contaminated by the defective sew- 
erage, there are many thousand inhabitants, with 3,994 privies, drink- 
ing the water from 140 wells. 

In the southern region, with 197 fatal cases, there were 140 pumps, 
now reduced to 87 ; in the northeast, 84 fatal cases and 47 pumps, now 
reduced to 29 ; in the middle area, 179 deaths, 70 pumps, now 42 ; in 
the northwest, 114 deaths, 34 pumps, now 22. (The number of pumps 
here given is taken from map published by District Commissioners in 
1889, and list furnished May, 1894.) In Georgetown there were 52 
deaths, with 18 pumps.* 

It can be assumed that where there are the largest number of pumps 
there is the largest consumption of well water ; that well water is used 
most largely by the poor, and in those quarters of the city where the 
water and sewer connections are fewest j and that Potomac water is 
used chiefly where the water and sewer connections are most numerous. 

We know that water from the 310 pumps existing at the report of 
1889 was largely used by the people living on the 426 squares in which 
the 626 fatal cases occurred. 

Even by those having access to Potomac water, well water is largely 
consumed, on account of its being colder during the hot months of the 
year. 

The object of these considerations is to show that the soil underlying 
the city is being constantly impregnated with human excrementitious 
matter, and with all microorganisms therein contained, and that the 
water of wells liable to be contaminated with such material is being 
constantly and generally used as drinking water by the people. 

It is not an assumption that the well water thus consumed is infected 
and dangerous to health. It is a matter of chemical and bacteriolog- 
ical demonstration. 

At the end of 1890 there were 271 public pumps in service 5 17 of 
these were abandoned during the year as being no longer fit for use. 

In the report of the engineer of the District for 1889-'90, it is stated 

*The number of pumps here given, and as shown in map No. 2, is taken from a 
map published by the District Commissioners in 1889, and from a list furnished by 
them in May, 1894. The number may not be strictly correct, as errors have been 
found in the map of 1889. 



TYPHOID FEVER IN THE DISTRICT OF COLUMBIA. 



13 



that 75 per cent of the water of wells examined was found to be suspi- 
cious. In the northwest 71 per cent was bad or suspicious, in the 
southwest all examined were bad or suspicious, in the northeast 2 out 
of 3, in the southeast 40 per cent, and in the county 70 per cent. The 
report adds that the ouly excuse "for keeping the wells open is the 
filthy condition of the aqueduct water and the high temperature which 
it reaches in the mains in summer, often 85 degrees, which is far from 
palatable to the poorer classes, who are unable to purchase ice." 

The following year 9 wells were filled and abandoned. In the year 
ending June, 1892, of 57 wells examined 24.6 per cent were condemned 
or declared very suspicious; 14 were filled and abandoned. The wells 
of the county were, as a rule, more contaminated than the city wells, a 
condition due to the fact that the soil of the city is better drained by 
sewerage than that of outlying districts. 

The report for the year ending June 30, 1893, states that a larger 
number of wells were condemned than in the previous year, u owing 
to the large number examined from the low portion of the city in the 
southeast and southwest sections." Fourteen were found dangerous. 
This is the very section of the city in which the number of fatal eases 
was so great in the five years. 

The following report of bacteriological examinations of 13 wells, made 
for the committee by Dr. J. J. Kinyoun, fortifies these views of the gen- 
eral unhealthfulness of the well waters: 



Sample 
No. 



Location of well. 



Result of examination. 



Condition of 
water. 



Recommenda- 
tions. 



East side Seventh street be- 
tween M and N streets NW. 

L street between Sixth and 
Seventh W. 

East side Seventh street be- 
tween M and N. 

Tenth and S streets NW 



Sixteenth and Corcoran streets 
NW. 

Seventeenth and K streets 
NW. 

Tenth street between B and 
CNE. 

Third street and Indiana ave- 
nue NW. 
T and Eighteenth streets NW . 



Twenty-third and G streets 
NW. 

Eighteenth and S streets NW. 

K street between Twenty- 
first and Twenty - second 
streets JfW, 

Ninth and H streets N¥ 



Sewage bacteria. 

bacillus isolated. 
do 



Colon 



.do 



Sewage bacteria. Eecal bac- 
teria. Colon bacillus iso- 
lated. 

Ordinary forms usually 
found in water. 

Ordinary forms usually 
found in water, but in 
considerable quantities. 

Sewage bacteria. Colon 
bacillus isolated. 

Sewage bacteria 



Ordinary water bacteria, 
but in large numbers. 

Sewage bacteria 



Sewage bacteria In great 

numbers. 
Sewage bacteria. Colon 

bacillus isolated. 

Ordinary water bacteria in 
small numbers. 



Bad 

.-..do 

...do 

...do 

Good 

Suspicious . . 

Bad 

...do 

Suspicious . . 

Bad 

...do 

...do 

Good 



Well should be 
closed. 
Do. 

Do. 

Do. 



Should be kept 
under observa- 
tion. 
Do. 



Should be closed. 
Do. 

Should be kept 
under observa- 
tion. 

Should be closed. 



Do. 
Do. 



Should be kept 
under observa- 
tion. 



In the recently published report of the examination of the water of 
the city wells by Drs, Theobald Smith and Mew, 16 wells were reported 



14 TYPHOID FEVER IN THE DISTRICT OF COLUMBIA. 

as examined bacteriologically by Dr. Smith, and the conclusions reached 
were favorable to the general purity of the well water. Five wells only 
were found to contain fecal bacteria; the water of 4 was in good condi- 
tion, and that of 7 in need of improvement. 

The suggestion is made by Dr. Smith that the wells upon which a 
favorable report is made should be retained, that others should be 
improved, and that bacteriological examinations should be made at 
least once a year to determine the fitness or unfitness of the water for 
drinking purposes. He also suggests that wells considered safe should 
be so labeled. But is not the fact that some wells at a particular date 
contain fecal bacteria a sufficient reason for condemning the whole 
system? 

As long as causes of soil pollution exist, is not one well as liable, or 
nearly as liable, to contamination as another? And the fact that one 
well contains no bacteria, another a few, and another many, is no proof 
that all are not liable in different degrees to become at some time 
infected. To be under the necessity of labeling each particular well as 
healthy or unhealthy, after annual examination, is an endless task and 
a most unscientific procedure, for how many individuals who wish to 
quench their thirst will be influenced by the published statement 
impugning the reputation of a particular well! Even if the individual 
knows that bacteria are found, he will drink and take the risk. As 
sanitarians we must condemn the whole system, and advise an early 
abandonment of all wells as the only solution of the question. The 
advice contained in the report made to the Sanitary League we believe 
to be mischievous, and to involve a continued menace to health. 

It should be remembered that the water of the 16 wells reported upon 
by Dr. Smith is of those which have been permitted to stay, and that 
over 80 have within the last five years been condemned and filled up. 
Dr. Kinyoun finds sewage and fecal bacteria in 9 out of 13 examined. 
For how long a time will these now reported upon as free x from fecal 
bacteria remain so, with the continued presence of typhoid fever among 
us ? Shall we wait for the infection to take place, or shall we remove 
the possibility of the dissemination of the disease in this way? These 
are questions to which we should give no uncertain answer. 

The lesson of Yienna should teach us what this answer should be. 
From 1851 to 1874 well water of an impure character was used to a large 
extent. During this time the deaths from typhoid fever ranged from 
10 to 34 annually in every 10,000 of the population. In 1874 spring 
water of great purity was introduced, and the well water of impure 
wells was given up. The annual mortality rate immediately fell to 5, 
and in three subsequent years to 1.1. A good sewerage system was in 
existence long before this, but it had no effect in reducing the mortality, 
as sewerage without the abandonment of the drinking of infected well 
water is without effect. 



TYPHOID FEVER TN THE DISTRICT OF COLUMBIA. 



15 



One fact to which separate attention should be drawn is that many 
of our cases of typhoid fever are imported from without. At the end of 
the summer it is a frequent occurrence for the disease to develop in 
individuals who have just returned from seashore and other resorts, and 
a much larger number of our inhabitants go out of town now than for- 
merly. This is one means by which our mortality is increased, and 
fresh infection is added to that already existing. 

INFECTION THROUGH MILK. 

The dissemination of typhoid fever by the milk supply in the District 
has not been investigated fully enough to warrant any extended remarks 
or conclusions. It would be well to make this a separate matter of 
study. It is safe to assume, from the experience of many observers 
elsewhere, that typhoid fever is to a certain extent propagated by milk ; 
there is nothing in the condition of the dairies from which our supply 
is drawn to make us think that we are better protected from this dan- 
ger than other communities where epidemics have been traced to milk 
infection. 

There are 65 distinct places in the District where cows are kept and 
from which milk is supplied. 

CONCLUSIONS. 

It has been shown that in Washington there is a coincidence be- 
tween a soil polluted with the leakage of the excreta from typhoid 
fever patients, the drinking of infected well water, and an extensive 
distribution of typhoid fever; that where these two first conditions 
exist to the greatest degree typhoid fever is most prevalent. It remains 
to be seen whether the purification of the soil, and the abolition of the 
water supply from pumps, would lessen the disease. 

The belief that typhoid fever spreads by " soil contamination" would 
be much strengthened if other cities, with the same conditions, have 
diminished the percentage of the disease by draining the soil and 
abandoning the use of well water. 

(1) Typhoid fever increases in proportion to the saturation of the 
soil with decomposing organic matter, especially human excreta, and 
to the drinking of infected well water. 

(2) Typhoid fever decreases in proportion as a city is well sewered, 
and in proportion to the abandonment of the drinking of well water 
and of all contaminated water. 

The greatest diminution in typhoid fever has taken place in England 
and Germany, where expert engineers and liberal municipal govern- 
ments have combined in the work of sewering the principal cities. In 
the cities of Spain, Italy, Eussia, and Mexico, where the sewerage sys- 
tems are less complete, the diminution has not taken place. 

The history of Munich offers the strongest evidence on this point. 



16 TYPHOID FEVER IN THE DISTRICT OF COLUMBIA. 



From 1854 to 1859, when no means existed to prevent the fouling of 
the soil, the mortality was 24 to 10,000 inhabitants. From 1860 to 1865 
the sides and bottoms of the pits of the privies were cemented, and 
the mortality fell to 16.80. From 1866 to 1873, with partial sewerage, 
it was 13.30; from 1874 to 1880, with improved sewerage, it was 9.26, 
and from 1881 to 1884, with still greater improvements, it fell to 1.75 
to 10,000 inhabitants. 

The experience of Berlin is very instructive to Washington, as 
showing the difference in mortality in houses with sewer connections 
and in houses without them where privies were used. 

In houses with sewer connections there were 15.5 cases and 4.5 
deaths to 10,000 population. In houses without sewer connections 
there were 56 cases and 17.9 deaths. In sewered houses there was 1 
case to every 49.3 houses and 1 death to 137.5 houses. In nonsewered 
houses there was 1 case to every 9.3 houses and 1 death to 43 houses. 

In Dantzic, with a wretched system of privies, there were 10 deaths 
to 10,000 inhabitants. The introduction of an abundant water supply 
in 1869 produced no effect on the death rate. The city was sewered in 
1872. In the following twelve years the average mortality was 2.4 and 
in the last five years was only 1.5. In Breslau in 1866, without sewers, 
the mortality was 15.2 ; in 1876, with sewers, it dropped to 5.5 to 10,000 
inhabitants. In the cities of England, before any extensive sewerage 
systems were introduced, from 1850 to 1871, the mortality was 9; from 
1876 to 1884, it was 3.6, the change following upon a general introduc- 
of sewer drainage. 

Chart II, which accompanies this report, illustrates in a most strik- 
ing way the differences in mortality in sewered and unsewered cities, 
the percentage being to 10,000 population in five years, 1880 to 1884. 

In cities with good sewers and general water supply the averages 
were as follows: Munich, 1.7; Dantzic, 1.5; Frankfort, 1.4; Breslau, 
3.3; Hamburg, 2.6; Berlin, 2.9; Brussels, 3.3; London, 2.3; 28 English 
cities, 3.2; New York, 3; Brooklyn, 1.5; Vienna, 2.1; Washington, 4.6; 
Washington (1885-1890), 6.7. 

In cities without sewers or very imperfectly sewered the yearly aver- 
ages for each 10,000 residents were as follows : Paris, 9.9 ; Marseilles, 
12.8; Turin, 9.5; Naples (1881-1884), 7.1; Palermo (1881-1884), 13.1; 
Catania, 19; 281 cities in Italy (1881-1882), 9.5; St. Petersburg (1883- 
1884), 9.9; Eiga (1881-1882), 15.8; Budapest (1877-1881), 9.2; 20 Ger- 
man cities (1878-1882), 9.8; New Orleans (water supply from cisterns 
above ground), 2.7; Baltimore (abundant water supply), 4.8; Cincin- 
nati, 7.3. 

Chart in shows the reduction of mortality as a result of sewerage. 

Brooklyn and New York have the best sewerage systems in this 
country. New York has 300 miles of sewers, but Brooklyn is perhaps 
the best sewered large city. New York has a mortality of 3 and Brook- 
lyn 1,5. The mortality of Brooklyn, our best sewered city, is lower 



/ 



TYPHOID FEVER IN THE DISTRICT OF COLUMBIA. 



17 



than Munich, Berlin, Hamburg, London, Vienna, which are the best 
sewered cities of Europe. And when a city is said to be sewered this 
means that water-closets are substituted for privies and the soil is 
kept free from contamination. 

To turn, now, to other cities in this country, Baltimore, as Osier in 
his excellent report says, "has practically only surface sewerage. 
* * # T;h e excreta pass, for the most part, into privy pits, of which 
it has been estimated there are from 70,000 to 80,000, occupying one- 
twentieth of the entire surface of the city, exclusive of streets and 
parks." Leakage, he says, unquestionably occurs in a very large num- 
ber, with saturation of the ground in the vicinity. Baltimore has a 
mortality of 4.8, more than three times that of Brooklyn. 

Washington, whose sewerage system is very good in most respects, 
but with fatal defects which diminish its efficiency and with that 
equally great danger from soil pollution from its 9,000 privies, has an 
average annual mortality of 6.2 in the last thirteen years. This is four 
times the death rate of Brooklyn, twice that of New York, and the 
same as that of Philadelphia. 

The daily pollution of the soil by the fecal discharges of our patients 
suffering from typhoid fever, with the resulting contamination of well 
water, must be recognized as the chief source of the diffusion of the 
disease. It is a case of auto-infection. We are daily breeding the poi- 
son which poisons us, and the inevitable round from intestine to soil, 
from soil to well, and from well back to intestine goes on and on 
with the most tragic uniformity. We sustain all the conditions favora- 
ble to rapid and perfect propagation of the bacilli. Granches and Des- 
champs have experimentally shown that typhoid germs placed on the 
surface of frequently moistened ground will penetrate nearly 2 feet 
into the soil, and will there retain life for five and a half months. They 
multiply rapidly in illy drained soil, live for an indefinite time in privy 
vaults, and have a much longer existence in cisterns and wells than in 
running water. 

In Washington we supply all these necessary conditions — leaking 
privies for the reception of the excreta and their contained germs, a 
damp and illy drained soil for their reception and rapid growth, neigh- 
boring wells for the resulting, the inevitably resulting, contamination 
of drinking water consumed by a thirsty population. What more con- 
veniences can we supply? What more successful means can we adopt 
to raise our mortality to a point higher than that of Brooklyn, New 
York, Baltimore, and Boston? We are among the most successful cul- 
tivators of the deadly bacillary plant m this country. 

RECOMMENDATIONS. 

The committee would urge upon the Medical Society the importance 
of taking the initiative in the effort to control the spread of this 
H. Mis. 188 2 



18 TYPHOID FEVER IN THE DISTRICT OF COLUMBIA. 



destructive but preventable disease by urging upon our municipal gov- 
ernment and upon Congress the prompt adoption of measures to 
remove the causes to which this report has drawn attention. 
The measures to be recommended are: 

1. The immediate abandonment of all wells within the city limits, 
exception only to be made in case of the absence of the Potomac supply, 
and where the wells, after repeated chemical and bacteriological exam- 
inations, have been found to be free from all possible sources of dan- 
ger. But even these to be abandoned as rapidly as possible. 

2. Purification of the sewerage system already existing, by replacing 
as rapidly as possible all damaged or defective drains. 

3. The introduction of new sewers in advance of other improvements 
in parts of the city not now supplied with drainage, and the extension 
of the system as far outside of the city limits as the rapidly growing 
population demands, so as to prevent soil contamination. 

4. The adoption of some system by which the lower sections of the 
city can be more completely drained and the risks arising from the 
backing up of tide water and sewage prevented. 

5. The final and safe disposal of the sewage. 

6. To make all existing privies, vaults, or other receptacles of human 
excreta water tight, and by rigid inspection and penalties to prevent 
the danger from leakage and overflow. 

7. The early completion of the plans recommended by Col. Elliot, in 
charge of the Washington aqueduct, and now in course of execution, 
which have in view the sedimentation of the Potomac water, and ulti- 
mately the completion of works for filtration, the only proper method of 
purification. 

8. The suppression of all privies and the enforcing of the law to make 
sewer connections. 

9. Careful inspection of all dairies in the District from which our 
milk supply is drawn, and the enactment of a law by which no milk 
shall be sold in the District without a permit from the health office. 
The inspection should cover an examination at the dairies of all possible 
sources of infection, including the water supply. 

10. The urging upon the members of the profession of a careful colla- 
tion of all facts bearing upon the mode of infection in each case, and 
the advantage of reporting such facts to the society, and the propaga- 
tion of the doctrine that immediate disinfection of the stools is the first 
duty of the physician as guardian of the health of the community. 

G. L. Maoruder, 
W. W. Johnston, 
C. M. Hammett, 

Committee, 



O 




□cscoa 

ODD" 




\J4— 



"IE cms 



g: I : I 

czi at 

L 



c^cJs Vie? 




gfg^gH^raiH HIES ' 
]0«H E B3 S 1 §§0^0^^ 





H 






















Bsc 





HSBHHBBBlS fK 11- jpfi 



BBBaHBBB 
hsshbbhb: 



SHE 




BBBBBB5«BB h~llTTiri 




No. 3. 

ITT ©If WJ^TEI2i0OTf 

DEATHS FROM DIARRHEAL UStASES IN 
RESIDENCES WITHIN Tilt. < m ' LIMITS 

FROM tsas to isos, iNCttm. 



t 




1 




